Wednesday, September 19, 2007

Back in June I wrote a rather scathing blog that took Dr. Walton-Shirley to task for her position on Primary PCI. She was understandably upset that I would read into her comments something that she claims was either misread or simply not there and wrote this comment to take me to task.

I guess I really cannot blame her for being upset that I used her as the latest scapegoat for the failing medical establishment, but, I felt, and still do, that my position on the medical community as a whole was right on the money. So, in an effort to set the record straight on numerous fronts, let's get down to the nuts and bolts of my position. Then YOU can decide.

1. First, let's all understand something. In any debate there are two sides and both sides must anchor their end of the spectrum. Dr. Walton-Shirley feels the best use of time, talent, and money is to build more cath labs and train more people in how to use them so that IF you have a heart attack, you stand a better chance of being pulled back from the brink of death. Unfortunately, you have to first let people get so sick that they are about to die. My position is to use those same resources to prevent such disasters from happening in the first place. Take your pick. You cannot spend the money twice.

2. My role in this melodrama is to be as aggressive and relentless as the other side. This is not Little League. Like it or not this a "blood-sport" and that is not just a metaphor. People's lives and quality of life are at stake. I am not above spilling a little blood of my own along the way.

3. In my blog I praised Primary PCI as a wonderful tool. I miss my mother, my grandfather, and my uncle and wish a cath lab had been across the street when they were in the throes of their heart attacks. But, I wish, even more, that they had access to enlightened medical care 5-10-20 years before those sudden, life-ending events, care that would have PREVENTED them having a heart attack in the first place.

4. My biggest complaint is the complete lack of self-policing within the traditional medical community. There are ways to effectively prevent and treat heart disease that simply are not being disseminated by the so-called guardians of our health. I have had top-flight, (previously) trusted internists and cardiologists make the following statements to me and my relatives.

- (after a routine cholesterol panel) "I have seen 50 patients today and your LDL cholesterol is lower than all of them. Now stop worrying." (NOTE: My doctor said NOTHING about my abnormally low HDL cholesterol nor, given my family history, do more than a conventional Friedewald lipid panel).

- (after my brother was tested at my urging - not his doctor's - and diagnosed with high lipoprotein(a)) "Here, take this statin. It's magic!" (NOTE: Statins are completely useless for reducing lipoprotein(a))

- (after my first nuclear stress test) "There is no evidence of any obstructive disease. I would not do anything at this point." (NOTE: It has been established that you can have extesive CVD with no detectable obstruction)

-(a conversation after an uncle's triple bypass) "ME: Too bad you didn't have a heart scan. UNCLE: I did, seven years ago. My score was 1200 but my doctor said as long as my stress test was OK to ignore it." (NOTE: 1150 of the 1200 was in his LAD, the only artery receiving - count 'em, not 1, not 2, but 3 bypasses)

These were not schmucks but the best physicians we could find (and I'm damned good at it). Sorry, but I am not exactly the trusting sort anymore. In fact, I am as mad as hell!

SO WHERE IS THIS ALL GOING?

I do not fault Dr. Walton-Shirley for studying hard, working late, saving lives, and espousing ideas to save even more lives. If her ONLY intent was to make Primary PCI more available my ONLY question is whether this is the best use of resources. However, I am totally frustrated when the medical establishment continues to blindly put the cart before the horse. Dammit, it is just wrong to constantly beat the drum for more heart procedures when the overwhelming majority of them can be avoided. How about a little balance?

So, thanks for all the hard work and please do keep saving lives Dr. Walton-Shirley. As someone whose style is to be aggressive I admire the fact that you cared enough to fire back. Perhaps this will be the start of a wonderful professional relationship. We owe it to everyone to work together and limit "friendly fire." In fact, if I see your next published editorial is about cutting-edge prevention I guarantee I will write an equally effusive blog about a doc who "gets it." God knows we need more of them. But, don't be too surprised if I still get a little irritated when your colleagues fail to speak out about prevention and malpractice within your own ranks. But, I guess that's my job.

13
comments:

Hi there, Heart Hawk. I found your blog via Dr. Davis' Heart Scan Blog. I've read you off and on and I enjoy your commentary.

I was wondering ... It's been my experience that people, future patients, enter the healthcare system through insurance. And that they opt for a therapy or a procedure based on what their insurance will pay. So (rhetorical) ... do insurance companies make more money supporting invasive critical care procedures than they do long-term prevention strategies? I don't know. It appears they do. To me, insurance companies are key. They direct spending of healthcare dollars.

On a related topic ... if we elect someone into office who supports universal healthcare, a type that would involve more government funds ... I wonder how that might change how we use technology?

Hearthawk,Since I think we have more in common than you realize, I'll add a final word. The commentary by Dr. Davis tells us that the nation has no concept of what is really going on in areas like South Central Kentucky. Our area is a drain for your tax dollars. We can't get a smoking ordinance passed in the next town. We serve our kids pizza at every school lunch and the kids spend half the year "learning about health" instead of combining an activity program simulaneously. They've never seen anything but "white bread" here and are insulted if French fries aren't on every single plate. Although we dream of the ability to meet folks before they ever get into trouble with heart disease, the reality is that we are a *MASH unit, complete with a pack of camels in every pocket and purse. The idea of cushy boutique preventative medicine is a dream for us, but when you have 3 cardiologists with 40,000 active charts where 1 in three residents of this 5 county area smoke ( including 1 in 4 pregnant women)the reality is a daily grind of acute care to treat the dying that you've never met.I ABSOLUTELY AGREE that more dollars need to be spent on prevention and education but we already have such a populace of sick and unknowingly dying patients that we can't slack on acute care just so we can appear to be politically correct. But what am I talking about ?? Not many people in this are even know what the term politically correct even means. I spent my Sunday morning putting in a balloon pump on a very nice dying patient as my first introduction to him. It's typical. I don't get the opportunity to meet these people before hand except on rare occasion. Our office is booked for 8 weeks in advance with chest pain patients who often have never seen a beta blocker but they already have CAD BEFORE they get in. If any patient slot opens up, it is covered like a fumble at the Rose Bowl by some of our office staff to try to work others in. When the patient presents with the disease process far down the pike, we MUST add what we know will work. ANY RISK FACTOR PROFILE and ANY EVIDENCE OF HEART DISEASE deserves an exercise prescription, nutrition and appropriate medical therapy. I apologize that statins seem to be unpopular but fewer people die on them so I prescribe along with diet, fish oil, exercise. Heart Hawk, I'm sorry that your family member died but mine die too. I never met my grandfather. My uncle infarcted at age 40. My other uncle died of lung cancer. Both of my inlaws died of lung cancer. It's really fun growing up here never knowing your grand parents because they die in the name of big Burley. My father had 7 vessel CABG at 71 and the only reason he didn't meet the same fate as his brothers is that I did a stress exam on him every single year until he finally manifested an abnormal test. I treated his hypetension. He quit smoking. I tried to get him to eat differently and to take statins, but that was a losing battle ingrained in his upbringing. He's alive though, unlike his other family members. That's why I do what I'm doing, for everone's familiy members that I can impact. You still don't understand my stance. In Europe, cath labs without surgical backup serve as life saving stations for heart attack pts. In Kentucky, we have two cath labs in the state that are allowed to perform emergency PCI for ST elevation with CABG backup. WE have 11 hosptals that are capable but because of uneducated and uninformed attitudes, people are still being required to be transported 1-3 hours for heart attack care DURING THEIR HEART ATTACK. In those 1-3 hours you automatically doom the patient to more CHF medications, disbility, money for devices and early death. All of which steal any resources that could be applied to prevention. Now I turn around and the uninformed fellow professionals who have no idea what we are dealing with throw dirt while we are doing CPR. Incredible. I just returned from the European Society of Cardiology Meeting last week where I hoped to learn more about Dr. Widimsky's health plan for the Czech Republic. He took a map of the country and changed the transfer strategies has now normalized the non-cath lab mortality to the same mortality as hosptals with cath labs. He leveled the playing field for all heart attack victims. Now he probably has more funds to do some prevention. While we continue this stupid debate in America, people are dying by the HOUR for lack of an organized approach to AMI care. Many physicians who accuse us of representing the STATUS QUO don't understand what our STATUS QUO is. I have three patients who infarcted below the age of 20. Do you not think that as a physician I'd like to have the resources to prevent that??? If Dr. Davis thinks he can help us.....bring it, but I doubt he''ll enjoy his daily schedule that generaly runs from 6:30 am until 10 at night. We've been recruiting for 4 years with no success. WHy??? I sent my daughter off to college this year realizing I've spent her entire lifetime at the hospital or on the couch reading echo's. It's not a whine or a complaint, it's a fact and it's why NO ONE wants to come help us. And NO, insurance companies do NOT pay me MORE for cathing a patient but when it's the right thing to do, you do it and if you are a physician worth your salt, you really won't know or care how much any service reimburses. I have no idea how much it costs to come see me. I hire someone else to take care of that and we do NOT require money up front. We do require a minimum monthly payment of ONE TO FIVE dollars per month to keep our computer from generating a bill to that patient. We do not turn down ANYONE For lack of resources. Dr. Davis, your fellow cardiologists at least in this are of the US are not your enemies. You should never make fun of us unless you walk about a week in our shoes. We have a largely unsophisticated population of patients, some of which don't read well and could never spell the Mediterrean diet but I cannot refuse care to these people just because they aren't Noble prize candidates. They are the uneducated, the sick, the dying and the addicted and they deserve therapy like anyone else. The best thing I can advise you to do in your frustration at the lack of prevention is to continue to deliver it everywhere you can. Meanwhile, don't throw stones at those of us who are in the trenches. We'd love to have your option for a scheduled office visit to discuss the necessary preventative measures but the ER just keeps calling. But you can't just come into an area and decide today that we're going to stop treating dying patients in favor of setting up a discussion booth about the mediterranean diet. The machine does not just stop grinding in favor of an ideal or a fantasy. We don't have smoking ordinances in this area. I crop dust the city with Chantix because it seems to be the only thing that has ever worked. I group council families outside of the room of every single heart attack victim and offer all of those family members free prescriptions. I contact our congressmen to beg for changes in school lunches and to implement REAL physical education programs. I write newspaper articles, talk to schools, women's organizations and our fellow physicians about ANY TOPIC to decrease our local mortality whenever I can.....but the reality is that I DON"T HAVE TIME to do it justice. If you think you can do any better here, we are recruiting. Have at it.

Today marks the 5th anniversary of my triple bypass procedure and I'm coming up on the 9.5 year anniversary of a mild heart attack I suffered and the insertion of 3 stents a few days later. I'm 52 now so, do the math, my heart attack occurred while I was 42.

I'd been thinking that I ought to make some post somewhere on this 5th anniversary but I wasn't sure where I'd make it until I saw your post here.

So here goes...

Your point here is right on the money regarding the ignorance and/or negligence of the cardiology community in addressing the issue of prevention.

Dying young was not something I have been particularly keen about so I have spent more than a little time trying to educate myself about how to reduce my risk.

For a while, the cardiologists in my HMO appeared extremely knowledgeable and, after all, they had saved my life, so shouldn't I trust them?

Over time, however, through web browsing and research only, I became more confused because of the contradictions in statements about what caused atherosclerosis and about recommended treatments. When confused, I'd ask questions of the same cardiologists who had saved my life and it became clear after a year or two of my own research that they really had little knowledge of what the state of the art was in preventing atherosclerosis.

True story: I was on a tread mill for a checkup about 2 years ago and the test was going fine and the cardiologist who I credit for making the decision to get me to the cath lab that led to my getting needed stents was monitoring the test. So, I was trying to pump him for his thoughts about latest LP(a) developments, etc. and he finally said to me: "You know, you know more about this than I do." And then he went back to discussing his European vacation with the Tread Mill tech...

I was floored.

So, can I understand your having an aggressive attitude toward these "doctors of cardiology"? hmmm... Let me think....

At long last, I've come to the conclusion that we live at a time of great flux in cardiology science. In 25 years, the current emphasis and best practices for prevention will be commonplace and that will be fantastic for my kids.

But I'll be dead in 25 years if I rely on the advice of "cardiologists" like the ones at my HMO or wait for Dr. Melissa Walton-Shirley's fantasy of more crisis management centers to be in place.

Look, I'm grateful that the coronary artery disease crisis management procedures exist and I'll be the first one to do them again if I need them. And clearly, Dr. Walton-Shirley is a competent physician with intent that is only positive toward assisting her patients. My point, like I take yours to be, is not to single her out.

Unless/until I need those procedures, what I really need (and what, IMO, everyone needs) is informed and clear advice about PREVENTION and this is what too many general doctors and cardiologists are unable to provide.

===================

I discovered Dr Davis' HeartScan blog and the TrackYourPlaque program within the last month. I just got the Track Your Plaque book last week and I finally feel like I'm in touch with a cardiologist that I can ask informed questions of and get an informed answer.

IMO, the great thing about Dr. Davis' work is this: He's not off in some left field about some single dimension of the problem. Instead, he is informed and very clear about the issues that need to be addressed to dramatically reduce risk:

Just about the time I pigeon-holed Dr. Davis as a guy who knew a lot about "tech heart scans" but probably not a lot about other things, I realized that he could intelligently discuss 3 major lipid testing approaches in detail, and then when I thought, "well, he's really good for heart scanning and blood testing" THEN, I realized he was the writer of a significant number of articles and brief reviews about heart disease related supplements for the Life Extension Foundation.

If there is another individual or comprehensive program or book that deals with each of the 3 critical dimensions noted above adequately, I sure haven't seen it.

I need to further educate myself on the program and get going on program implementation in my life.

But I can't tell you how terrific it is to feel like I now have a grip on the critical dimensions of the problem (the 3 noted above) and have access to the knowledge required to dramatically reduce my risk of sudden death by heart attack.

Kudos to you and Dr. Davis for pressing these issues!

As for me, I'm grateful to be alive and for all the assistance I have received over the last decade in staying alive. I hope this post constitutes a sufficient "pay it forward" on that debt I owe to others.

Well it sure sounds as if we have one hellva discussion going on here. I would like to take part in it. Dr. Walton-Shirley, first off, thank you for all your dedication to the emergency care you provide. What an honor it must be knowing you are saving someones life in a time of need. You say you're not an interventionalist but you do procedures? My guess is that you work for a hospital based system where you are getting paid by the amount of procedures your doing and not by the amount of lives you are saving? Dr. Davis now YOU need to be applauded for your dedication to prevention of heart disease. I see you wrote you have done over 5000 procedures. My guess is you had gotten sick and tired of putting a band-aid on the wound? You clearly are devoted, well educated and passionate about your work with heart disease. Let me ask Dr. Walton-Shirley this question...how many of your patients do you actually spend time with telling them what the cause of their heart disease is? And I don't just mean telling them their HDL is too low or their LDL is too high? You and I know that there is so much more than that. We all have choices to make and mine are certainly not to serve my kids pizza for lunch or go to a cardiologist that practices medicine for the "buck." Dr. Walton_Shirley, we thank you. Dr. Davis, THANK YOU for saving our lives. May there be many more of you in the future.

Reading your reply, I have the opinion that you are looking for understanding for the long hours you put in, and the family time missed as a result. And working from 6 in the morning till 10 at night is a long day by anyone’s standards and missing out on large amounts of your daughter's young life is truly tragic. But to state the obvious, to prevent a cardiac event from ever occurring will result in less hours worked for you and more time spent with your family.

Please, too give people more credit. I was born in rural Georgia and I will fully admit I'm not a world class speller, nor a fantastic writer, but I do care about my health and will do what I can to prevent a cardiac event from occurring. And I think you will find most of your KY citizens believe the same. I'm not a doctor but was able to convince several that live on my street and in my family the wisdom of cardiac prevention by following one of the more famous doctors preaching so, Dr. Davis, Dr. Agatston, and Dr. Whitaker. The problem I believe you will find many have with doctors and the health system is the confusing information provided on how to prevent heart disease - eat a low fat diet, a high fat diet, carbs are good, carbs are bad, etc. With the fantastic success prevention doctors are having in their practise, finally there is an answer to preventing a heart attack that works.

Dr. Walton Shirley makes a very eloquent case for increasing the availability of cath lab procedures to patients who present with chest pain due to insufficient blood supply to the heart muscle.

The problem that hovers around this discussion, and where I think Heart Hawk and Dr. Davis may diverge from her, is the element of greed that pervades the many hospitals that are not in the rural Kentucky trenches, and instead are installing stents in people who present with stable angina and are at least attempting to charge the health care system $36,000 a pop.

I suspect that Dr. Walton Shirley understands that cath labs are expensive and will not be installed in a widespread fashion unless the health care profit motive is factored in. Her editorial states:

"Elective percutaneous coronary intervention programs should be opened simultaneously in order to increase acuity for procedures and optimize equipment utilization."

Perhaps I am misunderstanding what she is saying here, but it sounds like she might be acknowledging that some not-so-necessary procedures should be performed so 1)the people who work the labs can get enough practice to be skilled when they are really needed, and 2) to "optimize equipment utilization" (which sounds to me like it might be saying that if you spend a lot of money equipping the country with a cath lab on every corner, the hospitals are gonna want to get their money out of the equipment).

The problem is, who will pay for those "elective" percutaneous coronary interventions? Who will get these in South Central Kentucky? Where does the "right" to get the intervention paid for end and the "election" to get it begin? To a carpenter, every problem is a nail and the hammer is always the solution. And isn't that the rub? The equipment costs money to buy, install and operate. To get the hospitals to install it, we'll have to let them use it on people who maybe don't really need it. Or use it on people who won't have a significantly better outcome than if they just were treated aggressively with medication alone (accept her belief that the world as she knows it will not follow a rigorous multi-faceted preventive regimen like Track Your Plaque). And nobody will be willing to admit that the patient really didn't "need" the intervention. So insurance, or Medicare, or Medicaid, will have to pay for it.

So - how much of the health care resource pie do we let them skim as the price of having the cath lab there when someone really needs it? How much long-term expense is caused by the heart muscle damage that the long distances between cath labs now causes? How does that compare to the money spent on unnecessary elective cath procedures she argues are needed for practice and "equipment optimization"?

Money saved is not the only measure. These are emotional decisions when they are posed in terms of you or me or our family and whether the life of a loved one can be saved if the intervention becomes more widely and quickly available. The difficulty in a system like ours, where money drives availability, is getting the kind of cold, hard data that can answer the question of how resources should be rationed. That's what this ultimately will come down to.

I can't say who is right or wrong on this. Dr. Walton Shirley is undoubtedly correct that there is a large segment of the population that is destined to need to have a vessel opened if their life is to be saved or if their heart muscle is to have a chance at being properly functional. We're already pregnant. Dr. Davis is undoubtedly right that the system needs to spend much more of its resources identifying patients who are at risk earlier, when preventive strategies can be used to avoid these costly interventions. Both might agree that the proper degree of effort responsible government should take in promoting healthy lifestyles is seriously lacking.

One thing is very clear: Both these people are passionate, dedicated, and both have what appears to me to be very valid points of view. I would love to get them together and hear them hash this out (and perhaps identify points of agreement) in a forum like the Diane Rehm show on NPR. This is an extremely important debate, at the core of the evolution of our health system in this country. Keep talking!

It's not often I hear someone articulate my thoughts so thoroughly. You just did, warren. That was considered and informed. A very approachable synopsis of this debate. It's a shame it's buried here in comments.

Question...Say you build cath labs. Say insurance companies decide, after they're built, to limit coverage for elective use of them. How will hospitals recover their costs? I don't mean to be cynical here ... but do hospitals cut a deal with insurance companies ... agreeing to cap charges if insurance companies don't restrict coverage? Does anyone know?

Yes, low-carbing has done wonders for my lipids. Sad but true, I am skinny yet still suffer from maladies more normally associated with overweight people. I haven't discovered the reason but I'm working on it.

Stent has proved to be a life saving tube for cardiac patient which is used in angioplasty surgery. The tube is a tiny, expandable, mesh-like tube made of a metal such as stainless steel or cobalt alloy. A cardiac stent is a small tube that is used to widen arteries supplying the heart that have narrowed. Stent for heart is sold by different companies in the world.Stent for heart

Under which condition would I consider myself "cured" of Coronary Artery Disease (CAD)?

About This Blog

I am a numbers guy, an engineer, MBA, and for the real numbers geeks, a Six Sigma Black Belt (statistics on steroids). I am also a heart disease sufferer. It took my mother, her brother, and their father. One minute they were alive and symptom free, the next they were dead. No good-byes, just gone. So, I became a heart health activist and resolved that I will die some other way.
This blog is about my journey to save myself and others, unearthing advances and atrocities, separating hope from hype, and delivering the unvarnished truth about curing heart disease, both good and bad.
So, hold on tight. I promise you a hell of a ride!